However, in order for this data system to provide the important quality assurance assistance of which it is capable, complete and accurate reporting is essential. At this point this goal is not being met. A review of the NYPORTS data as submitted to date and contained in this report confirms this fact. The regional variation in reporting cannot be explained away by differences in hospitals or case-mix. It is evident that there is serious under-reporting occurring. The report goes on to indicate those 25 individual hospitals where the volume of reporting is extremely disappointing. Efforts in these hospitals, as well as all facilities across the State, must be re-doubled to improve the identification and reporting of occurrences.

The Department does want to work cooperatively with hospitals. However, we cannot tolerate continued under-reporting. The Department will impose sanctions and fines against any hospital that is not complying with the NYPORTS reporting requirements. In addition, as we view the identification of adverse events as a key component of a hospital's quality improvement process, as well as the overall operation of the hospital, NYPORTS' compliance will be considered in relation to other hospital matters that come before the Department.

In closing, please join with me in striving to make NYPORTS a quality assurance initiative that will meet our mutual goal to make the care received by patients in facilities across New York State second to none.